Variability in anesthesiologists’ approach to the preoperative management of asthmatic children

Highlights

• No preoperative guidelines exist for asthmatic child referred to elective surgery.

• A national survey showed substantial variability among pediatric anesthesiologists.

• A relative homogeneity exists for the stable, school-aged asthmatic child.

• Further studies and implementation of consensus guidelines are needed.

Abstract

Objective

No consensus guidelines exist for the preoperative treatment of asthmatic children referred for elective surgery. We investigated the attitude of pediatric anesthesiologists to this issue.

Design

A questionnaire survey was conducted.

Setting

National survey.

Subjects

Certified Israeli pediatric anesthesiologists from all 24 general hospitals in Israel.

Measurement

Twenty-one questions regarding the approach to preoperative management of asthmatic children including 6 case scenarios with a variety of clinical situations and treatments of asthmatic children. The results were compared with the attitude of pediatric pulmonologists recently published using a similar methodology.

Main results

Forty-four pediatric anesthesiologists from all 24 general hospitals in Israel responded. Twenty-five percent of pediatric anesthesiologists answered that, in addition to pediatric anesthesiologists, the primary pediatrician should be consulted, and 70% believed that a pediatric pulmonologists should also be consulted. Overall, results showed a wide variability between responders especially for preschool children and unstable school-aged asthmatic children for both disciplines. The variability referred to the use of any treatment, bronchodilators, inhaled corticosteroids and their combination, addition of systemic corticosteroids, and the length of preoperative treatment. Compared with pediatric pulmonologists, a better within-discipline agreement was observed by the pediatric anesthesiologists for stable school-aged asthmatic children with a lower inclination to augment preoperative treatment (P< .001). No difference was observed for the preschool children with asthma and for the unstable school-aged asthmatic child.

Conclusions

A wide variability exists in pediatric anesthesiologists’ approach to the preoperative management of asthmatic children for most common case scenarios. This is probably explained by the heterogeneity of asthma, the type of surgery, the lack of guidelines, and the paucity of data. Similarities as well as differences exist between pediatric anesthesiologists and pulmonologists. Further studies and implementation of consensus guidelines are needed.

Introduction

Asthma is the most common chronic disease in children. Almost 10% of children are asthmatic [1], [2]. Anesthesia, surgery, and endotracheal intubation in asthmatic children are risk factors for bronchospasm, laryngospasm, perioperative cough, desaturation, and complications related to air trapping [3], [4], [5], [6]. In addition, increased cortisol secretion during stress from anesthesia and surgery may be impaired because of the continuous use of inhaled corticosteroids or frequent administration of systemic corticosteroids [7], [8]. Findings of studies in adults suggest that preoperative systemic corticosteroids and bronchodilators decrease the incidence of bronchospasm and pulmonary complications [6], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17]. Hence, elective surgery may require preoperative preparation of some children with asthma. This is also advocated by the Global Initiative for Asthma [18]. Several review articles suggest strategies for the perioperative treatment of the asthmatic adults and children [6], [19], [20], [21], [22]. Nevertheless, these are not based on controlled studies, and no formal guidelines by either the anesthesiology or respiratory societies have been introduced. In the absence of preoperative guidelines, there is a risk for last-minute unnecessary cancellations of surgery, or potentially, perioperative complications may ensue.

In a national survey among certified pediatric pulmonologists in Israel, we have previously shown that although it was widely accepted that preoperative assessment was required, a large variability in preoperative management of asthmatic children existed [23]. However, because the pediatric anesthesiologists are the professionals who are responsible for the preoperative decisions and are those who actually encounter and assess those patients before surgery, we investigated this problem among this discipline. We hypothesized that because there are no formal recommendations, a uniform management strategy does not exist, and if a variety of approaches was revealed, it would highlight the need for specific guidelines. The aim of this study was, therefore, to evaluate the attitude of pediatric anesthesiologists regarding preoperative management of asthmatic children using a national survey.